sometimes there are things that you say about work-related topics that you think you should only say with friends at the bar and then it turns out other people are thinking about it. like, ‘why can’t haiti be part of africa?’ and then this happens. my growing feeling is that there shouldn’t be such a divide between what you talk about at the bar or in hushed tones at a conference because there a lot of lessons to be learned, even if some connections are wacky/wrong and some process information is sensitive.

anyway, another such of my comments that i feared was un-PC or not fully substantiated was about the similarities between BRAC’s shastyashibikas in bangladesh’s health system and Mary Kay or Tupperware women (I don’t know about many Mary Kay or Tupperware men but am happy to learn!) in the US.

i have a fairly limited understanding of Mary Kay and Tupperware: along with Discovery Toys and Pampered Chef, I went to some parties with my mom growing up and remember examining the catalogues. i also remember the woman with the pink car at the Mary Kay party and I recall the Pampered Chef party being somewhat an excuse for mimosas and chatter – but also getting a cool (and much-used) slap-chop precursor out of it and a neat-o cooking demonstration. my understanding of the 1950s, 60s, and 70s Mary Kay and Tupperware scene is almost certainly Norman Rockwell-ized but I have a vague sense of the role they might of played in burgeoning post-war female employment and empowerment in the US. i am sure there is an official study (or episode of mad men?) i should read and would be happy to be pointed to it. [the only tupperware-related TV show i remember was the short-lived eerie, indiana.]

anyway, when teaching about the BRAC model of health care delivery in Bangladesh for ‘SW 25 Case Studies in Global Health: Biosocial Perspectives,’ it always struck me to have unexplored parallels with Mary Kay (we used mostly gated GHD case studies but some similar info here). but, this never quite seemed like something to state widely and we didn’t really read about the empowering aspect of giving women this earning opportunity. so, then, imagine my surprise when the article ‘the avon ladies of africa‘ made an appearance last week, also linked to BRAC. yay!

inbangladesh, this system includes ‘shastyashibikas,’ or ‘health volunteers,’ who have played an important – but perhaps somewhat controversial – role in treatment completion for TB (e.g. seehere). more generally, these women receive a brief, basic health training and then work part-time to sell medicines, etc, door-to-door. basic criteria for these positions include being between 25-35, married but having no children under the age of 2, and preferably being able to write (in order to limit turnover and improve availablity and effectiveness). not only was this mechanism seen as a way to overcome spread-out rural populations – as is also mentioned in the nytimes article about uganda and the US at the inception of avon – but also strictures such as purdah on females’ out-of-home movement.

i think there is scope for this franchise model to do a lot of good in not only delivering appropriate health-related products but following up on their appropriate use and customer satisfaction (bonus points if the sellers have a way of tracking satisfaction info and sending it back up the supply chain). but, i have a few questions.

five key things.

1. door to door v parties. whyavon and not tupperware? of course, there is some reason why an avon (door-to-door model) might make sense in rural areas. but what about tupperware parties: bringing women together, learning about and discussing health issues, encouraging each other to obtain the necessary products. certainly there is evidence about the benefits (though not the necessity, here or here) of peer groups in changing behavior. has it been tried? what happened?

3. empowerment and within-company upward mobility. i‘d like to hear more discussion of whether/what are career advancement opportunities within these models (and, slightly more peripherally, whether these employment opportunities are changing views of the importance of schooling and skills-acquisition for females.) about five years ago, i did some work with the then-newish Health Extension Workers in Ethiopia, a new cadre of workers (e.g. here) with high-school + 1 or 2 years of training that focused almost exclusively on health education and preventative services, also relying on a door-to-door rotation (in their place of residence or nearby, generally). an awful lot of the young women with whom we spoke saw this as a temporary role, which they hoped to use as a back-door stepping-stone to becoming a nurse (a position for which they were not otherwise qualified). i think this mindset needs to be accounted for when considering investments in training and also the importance of trying to offer continuing incentives and opportunities to increase pay and status. thenytimes piece mentions that the ladies get a snazzy blue t-shirt and I fully understand the power of branded t-shirts, tote bags, etc. not exactly that pink cadillac but similar concept. still, how long does this keep workers interested? navaashrafhas certainly done work on incentive theory, related to health workers such as this, but it’d be good to hear more about it in action. is being an ‘avon lady’ for an effort like Living Goods seen as a a long-term career? could it be seen as such? i hope there are some balanced qualitative studies occurring about the experiences of these women (i.e. not just the testimony for one enthusiastic woman, as happy as i am for her).

4.local goods. it’s great that companies like unilever and others that have been focusing on the near-BOP consumer are looking on getting in on the action, providing a range of products that help ensure the income for the “avon lady” and the overall model of something like Living Goods, which still requires a lot of donor funding. but, it’d be awful nice to hear a bit about links to local industry in this – say, shea butter lotion – in some of these efforts as a means of further stimulating income and female labor-force participation.

5. supply chain lessons. i hope the lessons learned about the scope for text messaging to be used for supply chain tracking and stocking will be widely shared.

finally, will blue t-shirts ever get memorialized as songs as havepink Cadillacs (though i don’t think any of the songs have Mary Kay ties at all)? are there any incentive lessons to be learned here?

follow[ing] a 2010 Kenyan High Court judgement [that] courts could only deal with offenses carried out within the country’s territory… Kenya’s Court of Appeal rules the country’s courts have jurisdiction to try pirates caught in international waters.

i have previously discussed the bizarre origin of ‘magic bullets’ as a phrase used positively and aspirationally in public health – as well as the folly it represents: relying on a single approach to a public health problem rather than doing multiple, hopefully coordinated, activities.*

my feeling is that something silver-bullety is going on right now in discussions about addressing malaria treatment and parasite resistance to that treatment.

there is a big push — both to wisely spend malaria-treatment resources and to stave off parasite resistance to ACTs (artemisinin-based combination therapies, the current WHO-recommended first-line treatment for uncomplicated malaria**) — towards using rapid diagnostic testing (RDTs); further, towards coming up with incentives for people to choose a treatment commensurate with those test results (and to incentivize drug vendors to encourage clients to choose treatments that correspond with the diagnosis).***

diagnosis is awesome. those issues need attention. but…

there are other big components in effectively treating malaria and fighting resistance that seem to be getting too little attention because they lack a fancy acronym and cool technology aspect? because they are unsexy? and/or because they are hard to do and measure?

in any case, counterfeiting and improper dosing and usage of ACTs are also important issues and i just don’t hear them getting the same buzz.

first, whether it is the public sector or the private sector that ultimately delivers the drug to an end-user, ‘health systems strengthening’ needs to include increasing government (or private?) monitoring, testing, and regulatory — pharmaco-vigilance — capacity to test drugs and check prices at port and mid-way through the supply chain, not just with the front-line workers. companies like sproxiloffer one way to approach this problem, though monitoring and regulation seems like the sort of thing you might want a state to be able to do.

second, just because good drugs get to front-line workers, it doesn’t mean the end user is getting the right drug for his/her body weight. butthat’s actualized access: affordable, available, acceptable, adaptable, AND USED. there’s evidence that workers with even limited training can make the right decisions about diagnosis and weight-class (including here and here).

but there is not a lot of evidence that most front-line workers possess this information, say, via regular government trainings. certainly my experience in northern ghana suggests that many vendors do not know about weight classes for drugs (preferring, if anything, to assign treatment by age) these private vendors are a major interface with the population seeking treatment for fever.

i recently heard someone promote pediatric formulations – syrups or enemas – to help guide vendors and users toward the right dosing decision even without understanding weight-classes (‘syrups are for kids’ is a relatively easy message). this seemed like very sage advice from shunmayyeung.

third, even though ACTs are only a 3-day (6-time) course of meds, people don’t finish them for all kinds of reasons.**** i was surprised at this problem when i first started looking at malaria after much more work on behavior around TB and chronic diseases – it seemed like such a short treatment course! but, it turns out a lot of people (including ex-pats!!! looking at you, JoT) don’t finish their malaria treatment course: like, 30% of people, in some endemic countries. there have been efforts at addressing this, for example here and again here, using follow-up text messaging. but, again, this just doesn’t seem prominent on the malaria agenda.

the last mile isn’t just getting affordable drugs into remote areas: it’s about getting good, affordable, and appropriate drugs in the right amounts into the bodies of the people who need and want them.

i have become quite fond of the ‘silver buckshot‘ metaphor to use in place of ‘silver bullets.’ in this case, treating malaria and protecting the effectiveness of malaria treatments requires looking at diagnosis, pharmaco-vigilance, and appropriate dosing and use. (and that’s without opening the prevention can of worms!)

keeping this bigger, balanced, and un-acronymed package of items on the malaria treatment agenda is difficult — but i hope it can be done.

*recognizing, of course, the problems with ‘planning’ and ‘coordination’ without allowing for ‘searching’ in terms of design and implementation.

**”it’s complicated” may be less-than-ideal as a relationship status on facebook — but it is definitely no good as a status update on your malaria.

***also, there is the tricky follow-up question of what to do if someone tests negative for malaria (moreover, what else to do if someone tests positive for malaria, given the potential for co-morbidities; these are topics for another time).

****too many pills, feeling better, saving the pills for the next illness, feeling nausiated from the pills, and so on

presidential 3: actually, the third debate was pretty upsetting. maybe the daily show will pull me out of it. a few things:

clever lines and the now-ubiquitous ‘zingers‘ stick, even if they are untrue (and, yes, i thought obama had some good ones but, no, they weren’t fully accurate). this actually makes the lesson of romney’s leaked first debate strategy not that one shouldn’t spend time coming up with zingers, it’s just that you shouldn’t let anyone find out that you are doing so because it sounds silly if you have to practice.

can we stop pretending that ‘flip-flopping’ is such a horrible thing? i agree that saying different things to different audiences is bad, as is the need to change one’s opinion because you spoke too hastily the first time around. but changing one’s position or, i don’t know, updating one’s prior based on new information, should be accepted, if not rewarded.

can the phrase ‘you’re all over the map’ be stricken from foreign policy debates? first of all, because that should simply be a statement of fact in a foreign policy debate. and, second, because it was not a statement of fact about last night’s debate. if we were talking about a map that, say, alexander the great (actually, erosthenes) had, then, yes, perhaps the conversation on 22Oct would have appeared to be ‘all over’ it.

really, nothing on ‘development’ efforts? no hearts and minds and bodies and lives and livelihoods? geez, mcgovern for president.

Like this:

“in the 18 months since the London-based Environment Justice Foundation (EJF) raised the £50,000 needed to buy and equip a small seven-metre community surveillance boat for villages in the Sherbro river area of Sierra Leone, local fishers have filmed and identified 10 international trawlers working illegally in their protected waters and have made 252 separate reports of illegal fishing.

images of the pirate ships and their GPS positions are analysed to establish the identity of the vessels and the evidence is passed on to European Union (EU) and African governments, fishing ports and other communities… in addition, it says, Panama and Korea, whose vessels have been repeatedly identified fishing illegally in Sierra Leonean waters, have agreed to act on the information provided by the communities.”